NURS 335 | N 335 Final exam study guide topics_Complete Updated 2025; A+ Guide.

N 335 Final exam study guide topics Antepartum (20%) Terminology & GTPAL nomenclature Key Terms:  Gravida = Pregnant  Para = Birth  Nulligravida/Nullipara = Never given birth  Primigravida/primipara = First pregnancy/birth  Multigravida/multipara = Woman has given birth multiple times  Antepartum = Before labor  GTPAL o G = Number of pregnancies o T = Number of term births (37 weeks or greater) o P = Preterm births (Less than 37) o A = Number of abortions (TAB) or miscarriages (SAB) o L = Number of living children  G/P o Number of pregnancies/ Number of births Diagnosis of pregnancy & signs: presumptive, probable & positive o Presumptive- changes felt by woman (vomiting, tender breasts, cravings, no period, frequent urination, enlarging uterus, syncope, nausea, fatigue) o Probable-changes observed by examiner (pregnancy HCG test, braxton hicks contractions, chadwick sign, hegar sign, goodell sign, ballottement sign) o Positive-signs attributable ONLY to the presence of a fetus (ultrasound, fetal heart tones) Nutrition during pregnancy & sources of nutrients: iron, carbs, protein, calcium Iron  Maternal hemoglobin formation  Liver, meats, whole grain or enriched breads and cereals, dark green leafy vegetables, legumes, dried fruits Carbs  Primary source of energy  Whole (fruits, vegetables, whole food grains) instead of processed food Protein  Growth of maternal tissue and expansion of blood volume; Secretion of milk protein during lactation  Meats, eggs, cheese, yogurt, legumes, nuts, grains Calcium  Maintenance of maternal bone and tooth mineralization  Milk, cheese, yogurt, sardines or other fish eaten with bones in, dark greenleafy vegetables except spinach or swiss chard, calcium-set tofu, baked beans, tortillas Hormonal influences during pregnancy Hormone Source Effects of changes during pregnancy hCG Fertilized ovum and chorionic villi Maintains corpus luteum production of estrogen and progesterone until the placenta takes over the function Progesterone Corpus luteum until 6-10 weeks of gestation, then the placenta Suppresses secretion of FSH and LH by the anterior pituitary; Maintains pregnancy by relaxing smooth muscles, decreasing uterine contractility; causes fat to deposit in subcutaneous tissue over the maternal abdomen, back, and upper thighs; decreases mothers ability to use insulin Estrogen Corpus luteum until 6-10 weeks of gestation, then the placenta Suppresses secretion of FSH and LH by the anterior pituitary gland; causes fat to deposit in subcutaneous tissues over the maternal abdomen, back, and upper thighs; promotes enlargement of genitals, uterus, and breasts; increases vascularity; relaxes pelvic ligaments and joints; interferes with folic acid metabolism; increases the level of total body proteins; promotes retention of sodium and water; decreases secretion of hydrochloric acid and pepsin; decreases mother’s ability to use insulin Serum prolactin Anterior pituitary gland Prepares breasts for lactation Oxytocin Posterior pituitary gland Stimulates uterine contractions; stimulates milk ejection from breasts after birth Human chorionic somatomammotropin Placenta Acts as a growth hormone; Contributes to breast development; decreases maternal metabolism of glucose; increases the amount of fatty acids for metabolic needs T3 and T4 Thyroid gland Increase in thyroid hormones supports maternal metabolism and fetal growth and development Parathyroid Parathyroid glands Controls calcium and magnesium metabolismInsulin Pancreas Increases production of insulin to compensate for insulin antagonism caused by placental hormones; effect of insulin antagonist is to decrease tissue sensitivity to insulin or ability to use insulin Cortisol Adrenal glands Stimulates production of insulin; increases peripheral resistance to insulin Aldosterone Adrenal glands Stimulates reabsorption of excess sodium from the renal tubules Fundal height progression The expectation is that after week 24 of pregnancy the fundal height for a normally growing baby will match the number of weeks of pregnancy — plus or minus 2 centimeters. For example, if you're 27 weeks pregnant, your health care provider would expect your fundal height to be about 27 centimeters. EDD calculation: Nagele’s rule o Nagele’s rule o Determine first day of LMP (last menstrual period), subtract 3 months, add 7 days plus 1 year o Alternatively, add 7 days to LMP and count forward 9 months o Most women give birth from 7 days before to 7 days after due date A&P of pregnancy-structure and functions Pregnancy:  Spans 9 months o 10 lunar months of 28 days (280 days total)  Trimesters o First: week 1 through 13 o Second: weeks 14 through 26 o Third: weeks 27 through 40  Total term pregnancy = 37-42 weeks Diagnosis of Pregnancy:  Early detector: HCG-Human chorionic gonadotropin o Detect as early as 7 days after conception o Gradually increases and peaks at 60-70 days then remains stable until 30 weeks o Detect in serum and urine (first morning void is best) o ELISA technology is how most home pregnancy tests work Diagnostic testing during pregnancy: NST, CST, BPP, GBS, Glucose tolerance test  Nonstress test (fetal activity determination) o reactive NST at least 2 15-bpm FHR accelerations lasting 15 seconds or more with fetal movements over 20 minutes (over 32 weeks gestation) o nonreactive NST  reactive criteria not demonstrated or met o unsatisfactory NST  inadequate external monitor tracing of FHR  Vibroacoustic stimulation o Variability with sound/vibration applied to abdomen  Contraction stress test (CST) o Evaluate fetal response to stress o Have to be having contractions and ready for labor  Nipple stimulation (releases oxytocin)  Give oxytocin via IV (so you can stop the infusion at any time) o A (-) contraction stress test is what we want to see o Indicated for pregnancies at risk for placental insufficiency or fetal compromise as a result of  IUGR  diabetes mellitus  Post term or 42 week’s gestation or more  nonreactive NST  abnormal or suspicious BPP Biophysical Profile:  Assess fetus at risk for intrauterine compromise  Used to assess fetal wellbeing  Assessment of 5 fetal variables o breathing movement (the lungs are practicing by taking fluid in & out of the lungs) o body movement o Tone o amniotic fluid volume o FHR reactivity-non stress testing  Indications for testing o decreased fetal movement with subsequent non-reactive NST o management of IUGR o preterm, diabetic, and post term pregnancies o PROM-early dx of fetal infection Group B Streptococcus (GBS):  Common normal flora of GI tract o 1 in 4 women have GBS in the vagina  Leading cause of infection in the newborn o Respiratory (most frequent), meningitis, sepsis o Prematurity increases this risk  Testing routinely done between 35-37 weeks o Vaginal swab, 3 day culture o Results valid for 5 weeks o Rapid test available for unknown status in labor, 75 minutes  Prophylactic antibiotics: 4 hours prior to delivery (to decrease bacteria in the vaginal tract)o Ampicillin or cephalexin o Also recommended for unknown GBS status  Monitor newborn for s/s of resp infection Glucose Tolerance Test:  The oral glucose tolerance test is administered after an overnight fast and at least 3 days of unrestricted diet (at least 150g of carbohydrates) and physical activity  The woman is instructed to avoid caffeine because it increases glucose levels and to abstain from smoking for 12 hours before the test  The 3 hour OGTT requires a fasting blood glucose level, which is drawn before giving a 100-g glucose load  Blood glucose levels are then drawn 1, 2, and 3 hours later  The woman is diagnosed with GDM if 2 or more values are met or exceeded Body changes during pregnancy Changes to the Uterus:  Changes in size, shape, and position o Hegar sign- The softening of the lower uterine segment; Allows the uterus to go forward on the bladder o By 10 weeks, the uterus is about the size of an orange o After 12 weeks, the uterus starts to get bigger due to the growing fetus  Changes in contractility o Braxton Hicks sign- “Practice contractions”; Women will feel the uterus tighten up, but it should not be painful; Tend to get more frequent closer to the delivery time  Uteroplacental blood flow o Uterine souffle- Sounds made by the uterine arteries (should be same as uterine pulse) o Funic souffle- Sounds made by the umbilical vessels (should be the same as the baby’s HR)  Cervical changes o Goodell sign- A softening of the cervix; Makes it more friable  Other changes o Ballottement- If you push on the cervix, you can feel the baby bouncing under your hand o Quickening-first recognition of fetal movement  14 to 16 weeks for multiples  18-20 weeks for primips  Lightning- The baby takes pressure off and starts to descend (which is why the baby is lower @40 weeks than 36 weeks) Vaginal and Breast Changes:  Vagina and vulva o Increased vascularity to the area; Can cause the cervix to change color o Chadwick sign: violet color to cervix & mucosa (probable sign) o Leukorrhea: white vaginal discharge o Mucous plug formation; Discharged prior to labor Breasts o Fullness, increased sensitivity o Nipples and areola become larger and more pigmented o Increased vascularity o Montgomery’s tubercles: hypertrophied sebaceous glands; more developed on the areola (help lubricate things for breastfeeding) o Mammary glands grow during 2-3 trimester o Colostrum: early as 16 weeks for some General System Changes:  Cardiovascular system o Blood pressure: supine hypotension (baby blocks vessels when the mom is laying) o Blood volume and composition: increases by 30-50%; Will look like anemia; Low hematocrit o Cardiac output: increased workload due to blood volume increase o Coagulation: increased ability to coagulate  Respiratory system o Diaphragm gets displaced as the baby grows; SOB o Increased estrogen increases vascularity o Pulmonary function: nasal congestion & bleeding, voice changes, dyspnea at rest  Renal system o Anatomic changes: ureters and renal pelvis dilate, increase urine storing in bladder, UTI o Less tubular reabsorption of glucose; Increased volume so glucose goes into the urine o Functional changes: GFR increases, some glucose & protein in urine o Fluid and electrolyte balance  Basal metabolism rate increases: mom gets her own private summer! (makes mother hot)  Integumentary system o Chloasma or Melasma- Mask of pregnancy (hyperpigmentation); tends to fade after delivery o Linea nigra- Pigmented line that starts at the pubic area and grows up to the umbilicus o Striae gravidarum- Stretch marks o Palmar erythema- Color change in the palm of hand o Gum hypertrophy- Bleeding gums o Acne, nails, oily skin  Musculoskeletal system o As the baby gets bigger, the mom may experience lordosis (curving inward of the lower back)  Neurologic system o Increased vascularity and estrogen can cause carpal tunnel syndrome (edema around the nerves)  Gastrointestinal system o Appetite- Pica (craving non-food items; clay, flour, cornstarch), weight gain (25-35 lbs.) o Mouth  Bleeding gums  Excessive salivationo Esophagus, stomach, and intestines  Hiatal hernia (15-20%); Acid is refluxing back into the esophagus o Gallbladder and live  Gallstones  Gallbladder discomfort o Abdominal discomfort  Appendix displaces  Endocrine system o Pituitary and placental hormones o Thyroid gland  May get larger  Increased T3 and T4 levels PIH, Pre-eclampsia: s/s, diagnosis & treatment Hypertension in Pregnancy:  Gestational HTN Disorders o Gestational HTN  Mild HTN after 20 weeks without proteinuria o Preeclampsia  HTN after 20 weeks with proteinuria o Eclampsia  Seizure activity in preeclamptic woman  Chronic HTN Disorders o Chronic HTN  HTN diagnosed before 20 weeks o Superimposed preeclampsia or eclampsia  Chronic HTN with new onset proteinuria Preeclampsia:  Pregnancy-specific syndrome  The mom’s body is acting in an immune antigen kind of way  Often occurs with first pregnancy or first pregnancy with a new partner  Hypertension develops after 20 weeks of gestation in previously normotensive woman or new onset of proteinuria in hypertensive woman  Proteinuria (≥1+) & pathologic edema  Reduced organ perfusion & vasospasm  Etiology o Signs and symptoms develop only during pregnancy-cure is delivery of infant o Associated high risk factors: primigravida, primipaternity, multifetal pregnancy, morbid obesity, >35 y/o, diabetes, kidney dz, AA, chronic HTN, previous preeclampsia  Pathophysiology-Differs from chronic hypertension o Main pathogenic factor is not increase in BP but poor perfusion resulting from vasospasm o Arteriolar vasospasm diminishes diameter of blood vessels, which impedes blood flow to all organs and increases BP o Function in placenta, kidneys, liver, and brain depressed as much as 40% to 60%o Delivery of placenta is the cure-so patho is thought to be closely linked to placenta o Baby is not going to grow as they should because they are not getting enough nutrients  Causes ischemia and sends off toxins -> Organ damage in mom Mild Preeclampsia:  BP greater than 140 systolic or 90 diastolic (>20 weeks gest.)  ≥0.3 urine protein/creatinine ratio 300 mg proteinuria in 24 hour specimen  Urine output adequate; may have elevated serum creat.  Transient headache  May have visual changes  Some liver abnormalities or thrombocytopenia  Thrombocytopenia: platelets <100,000  Pulmonary edema may be present  Some reduction in placental perfusion Severe Preeclampsia:  BP greater than 160 systolic or 110 diastolic  Massive proteinuria not part of severe features dx anymore  Oliguria (less than 500cc in 24 hours) & elevated serum creatinine  Altered LOC or visual changes  Hepatic involvement: lab changes, epigastric and/or RUQ pain  Thrombocytopenia: platelets <100,000  Pulmonary edema or cyanosis  Fetal growth restriction GDM: s/s, diagnosis & treatment All women screened for GDM at 24-28 weeks  Those at high risk screened earlier and again at 24-28 weeks with glucose tolerance test (1 hour test)  Unable to meet increased insulin demand during 2nd & 3rd trimester o Insulin either not produced by pancreas or not utilized by cells appropriately  Antepartum care o Diet and exercise o Monitoring blood glucose levels  Fasting & 2 hours postprandial (after eating) o Medication  Oral hypoglycemics (glyburide, glipizide, metformin)  Insulin therapy-only option in the past o Fetal surveillance  Biophysical profile (BPP), size, amniotic fluid levels, fetal lung maturity o Intrapartum and postpartum care  Monitor BG during labor-may need continuous drip  Check BG postpartum & monitor baby’s BG (to prevent hypoglycemia in the neonate) PTL: dx, treatment Preterm Labor: Signs and Symptoms:  Uterine activity o Uterine contractions more frequent than every 10 minutes persisting for 1 hour or more  Discomfort o Lower abdominal cramping similar to gas pains; may be accompanied by diarrhea o Dull, intermittent low back pain o Painful, menstrual-like cramps o Supra-pubic pain or pressure o Pelvic pressure or heaviness o Urinary frequency  Vaginal discharge o Change in dischargeo Rupture of amniotic membranes  Predicting preterm labor and birth o Biochemical markers o Endocervical length Care Management: Home:  Lifestyle modifications o Decrease activities that result in PTL symptoms  Engaging in sexual activity  Carrying heavy loads  Standing more than 50% of the time  Doing heavy housework or climbing stairs  Performing hard physical work  Being unable to stop and rest when tired o Bed rest  Not a benign intervention  No evidence to support effectiveness in reducing preterm birth rates  Suppression of uterine activity: Tocolytics o Afford opportunity to begin administering antenatal glucocorticoids (betamethasone most common)  Accelerate fetal lung maturity & Reduce severity of respiratory distress in preterm births  24 hours after last dose for full effectiveness  Effective for 24-34 week gestation pregnancies o Terbutaline (Brethine)-beta adrenergic receptor o Nifedipine (Procardia)-calcium channel blocker o Indomethacin (Indocin)-prostaglandin inhibitor o Magnesium sulfate-calcium antagonist  Management of inevitable preterm birth o Labor progressed to cervical dilation of 4 cm likely to lead to inevitable preterm birth o Preterm births in tertiary care centers lead to better neonatal and maternal outcomes o Women at risk should be transferred quickly to ensure best possible outcome o Antenatal steroids given if between 24-34 weeks gestation  Consider use for 23 weeks at discretion of provider  First dose of antenatal glucocorticoids should be given before transferring mom Placenta previa & abruptio placentae  Placenta previa o Placenta implanted over cervix o Partial or complete o PAINLESS vaginal bleeding o Cannot vaginally deliver o Risks  More pregnancies (more scar tissue in the uterus) Multiple surgeries  Fibroids  Multifetal pregnancies (twins, triplets)  Abruptio placentae (placental abruption) o Detachment of placenta before birth of infant o Partial or complete o PAINFUL vaginal bleeding  Can have it without bleeding o Causes  Trauma to the abdomen (fall, car accident)  Drug use (cocaine, marijuana) Intrapartum (20%) 5 Ps of labor The 5 P’s of Labor:  Passageway  Passenger  Powers  Position of the mother  Psychological response Passageway: Pelvic Divisions:  False Pelvis: above brim (not indicative of pelvic adequacy)  True Pelvis: Measurement of pelvic adequacy o Pelvic inlet: upper margin of pubic bone o Midpelvis: short anterior wall; long curved posterior wall o Pelvic outlet: formed by ischial tuberosities laterally Passageway: Considerations:  Pelvis Shapes o Gynecoid-classic female type o Android-resembles male pelvis (heart) o Anthropoid (oval) o Platypelloid (sideways oval)  inlet: anterior/posterior-from symphysis pubis to spine midplane: symphysis to coccyx-normally the largest plane  outlet: transverse diameter-distance between ischial spines Passenger: Fetal Head:  Composed of bony parts that either hinder or facilitate childbirth  Key influential variables o Sutures o Fontanelles  Anterior  Posterior o Molding o Overriding sutures Passenger Fetal Lie:  Fetal lie – relationship of cephalocaudal axis of fetus to cephalocaudal axis of the mother  2 types o longitudinal lie – fetal cephalocaudal axis is parallel to the mother’s cephalocaudal axis o transverse lie – fetal cephalocaudal axis is at right angle (90 degrees) to mother’s cephalocaudal axis Passenger: Fetal Attitude:  Fetal attitude – relation of fetal parts to one another o expected fetal attitude is flexion o flexion of head/chin-to-chest, arms folded across the chest, and legs flexed up onto the abdomen o deviations especially related to the head will present larger diameters of the head for the pelvisPassenger: Fetal Presentation:  Presenting part: what is it? o determined by fetal lie, fetal attitude  Station o Fetal station refers to how far a baby's head has descended into your pelvis  Engagement o Engagement of the fetal head occurs when the widest part has passed through the pelvic inlet  Types of presentations o Cephalic or Vertex: 95% o Breech: frank, complete, footling o Shoulder: transverse lie Passenger: Fetal Position:  Fetal position – relationship of fetal presenting part to 1 of the 4 quadrants of the maternal pelvis i.e. front (anterior), back (posterior), or sides (right or left) o Most common fetal position is occipitoanterior o 3 notations used to describe fetal position  right (R) or left (L) side of maternal pelvis  landmark of fetal presenting part (occiput)  anterior (A), posterior (P), or transverse (T), depending on whether the landmark is in the front, back, or side of the maternal pelvis  Vertex presentationsVertex Presentations: Powers: Contractions:  Rhythmic and intermittent with periods of relaxation between contractions o Uterine rest between contractions  Phases: increment, acme, decrement  Characteristics: frequency, duration, intensity  Primary Powers of Labor: Purpose of Uterine contractions-dilation & effacement of cervix  Effacement – the taking up, drawing up, and disappearance of internal os and cervical canal into the uterine side walls  Dilation – widening of cervical os and cervical canal from less than a cm to approximately 10 cm  Dilation/effacement/station  2/50/-1Cervical Effacement and Dilation: Secondary Powers:  Pushing! Contraction of maternal abdominal musculature for fetal and placenta expulsion o Only after complete cervical dilation o If cervix is not completely dilated, bearing down causes cervical swelling or edema, lacerations, cervical bruising, and maternal exhaustion. o Valsalva  The mother is asked to take a deep breath, hold the breath (closed glottis), and push downward when uterine contraction starts Maternal Positions:  Upright position o Gravity assists with fetal descent o Facilitates dilation & effacement o Reduces pressure on major maternal structures  Lateral (side-lying) o Increases cardiac output o Improves perfusion to organs o Removes pressure on major maternal structures o Helps with back pain & facilitates counterpressure  Semi-recumbent o HOB elevated at least 30˚ o Convenient for fetal monitoring & exams  Hands and knees o Helps back labor o Facilitates internal rotation of fetuso Good for OP presentation Psychological Response:  Knowledge/preparation  Past experience  Stress response  Support  Social factors  Cultural factors s/s of labor, true labor vs false  Lightening – “dropping,” movement, or engagement of fetus into pelvic inlet o descent moves uterus downward and fundus away from diaphragm o results in ability of female to breathe easier o at same time, female may experience  leg cramps or pains  increased pelvic pressure  increased venous stasis that leads to lower extremity edema  increased urinary frequency  increased vaginal secretions resulting from congestion of vaginal mucous membranes  Sudden burst of energy o “nesting syndrome” – occurs approximately 24 to 48 hours prior to labor onset  Urge to clean and organize  Braxton Hicks Contractions o irregular, intermittent contractions that occurs throughout pregnancy o tend to disappear or stop with change in activity o discomfort centered in abdomen  Discomfort facilitate a belief that labor is occurring  “false labor” o cervical dilation does not occur o Can increase in occurrence closer to term  Cervical changes o Cervical ripening – softening of cervix  cervical rigid and firmness of pregnancy gives way to weakening and softening of cervix so that it may stretch and dilate in order to accommodate passage of the fetus  accomplished via enzymes (collagenase & elastase) that inhibit ability of collagen fibers to bind o Main sign of TRUE labor is progressive dilation & effacement of cervix Stages of labor, cardinal movements Cardinal Movements:  Engagemento When the biparietal diameter of the head passes the pelvic inlet, the head is said to be engaged in the pelvic inlet. In most nulliparous pregnancies, this occurs before the onset of active labor because the firmer abdominal muscles direct the presenting part into the pelvis. In multiparous pregnancy in which the abdominal musculature is more relaxed, the head often remains freely movable above the pelvic brim until labor is established.  Descent o Refers to the progress of the presenting part through the pelvis. It depends on at least four forces: pressure exerted by the amniotic fluid, direct pressure exerted by the contracting fundus on the fetus, force of the contraction of the maternal diaphragm and abdominal muscles in the second stage of labor, and extension and straightening of the fetal body.  Flexion o As soon as the descending head meets resistance from the cervix, pelvic wall, or pelvic floor, it normally flexes so the chin is brought into closer contact with the fetal chest. Flexion permits the smaller suboccipitobregmatic diameter (9.5 cm) rather than the larger diameters to present to the outlet.  Internal rotation o The maternal pelvic inlet is widest in the transverse diameter; therefore, the fetal head passes the inlet into the true pelvis in the occipitotransverse position. The outlet is widest in the anteroposterior diameter; for the fetus to exit, the head must rotate. Internal rotation begins at the level of the ischial spines but is not completed until the presenting part reaches the lower pelvis. As the occiput rotates anteriorly, the face rotates posteriorly. With each contraction the fetal head is guided by the bony pelvis and the muscles of the pelvic floor. Eventually, the occiput will be in the midline beneath the pubic arch. The head is almost always rotated by the time it reaches the pelvic floor. Both the levator ani muscles and the bony pelvis are important for achieving anterior rotation. A previous birth injury or regional anesthesia may compromise the function of the levator sling.  Extension o When the fetal head reaches the perineum for birth, it is deflected anteriorly by the perineum. The occiput passes under the lower border of the symphysis pubis first, and then the head emerges by extension; first the occiput, then the face, and finally the chin.  Restitution and External Rotation o After the head is born, it rotates briefly to the position it occupies when it was engaged in the inlet. This movement is referred to as restitution. The 45 degree turn realigns the infant’s head with the back and shoulders. The head can then be seen to rotate further.Thus external rotation occurs as the shoulders engage and descend in maneuvers similar to those of the head. As noted, the anterior shoulder descends first. When it reaches the outlet, it rotates to the midline and is delivered from under the pubic arch. The posterior shoulder is guided over the perineum until it is free of the vaginal introitus.  Expulsion o After birth of the shoulders, the head and shoulders are lifted up toward the mother’s pubic bone, and the trunk of the baby is born by flexing it laterally in the direction of the symphysis pubis. When the baby has emerged completely, birth is complete, and the second stage of labor ends. Stages of Labor: Stage 1- Latent Phase: 0-6 cm:  Onset of regular uterine contractions  Cervix: slow effacement & dilation  Fetal engagement & descent  May have ROM or not  Pain level and time frame varies o Nulliparas: 20 hour average o Multiparas: 14 hour average o Sedation can slow progression  Wide range of emotions Stage 1- Active Phase: 6-10 cm:  Cervical dilation o More rapid effacement & dilation o Multiparas more rapid dilation  Progressive fetal descent  Increased discomfort with contractions o Pelvic pressure & urge to push with fetal descent  Nausea & vomiting common  Increased bloody show  Emotional changes Stage 2:  Complete cervical dilation to birth of infant o Perineum bulges, flattens, and moves anteriorly, perineum becomes thin, rectum stretches o Crowning-fetal head encircled by external opening of vagina (introitus) o Duration: variable o Cardinal movements: Allow passage of infant through the pelvis o Cord clamping-delayed? Stage 3:  Birth to delivery of placenta Placental separation o uterus contracts firmly, diminishing uterine capacity and placental surface area o signs of placental separation  globular-shaped uterus  increased fundal (top of the uterus) height in abdomen  sudden gush or trickle of blood  lengthening of umbilical cord out of vagina  Usually give Pitocin IV or IM either before or after placenta delivery Stage 4:  Delivery of placenta to 8 hours post  Physiologic & hemodynamic readjustment o moderate drop in blood pressure o increased pulse pressure o moderate tachycardia  results from  blood loss (avg. 250-500 cc)  reduced weight of uterus  redistribution of blood into venous beds  Repair of cervical or vaginal lacerations o 1st degree: superficially disrupts mucosa o 2nd degree: divides the perineal body (episiotomies) o 3rd degree: tear involves anal sphincter o 4th degree: tear involves rectal mucosa  Uterus should be contracted and midline  May experience: o Shaking o Urinary retention o Increased thirst & hunger EFM interpretation & actions needed for complications Placement of EFM:  A. Cephalic = head down  E. BreechMonitoring Contractions: External monitor (tocometer)  Timing o Frequency-beginning of one contraction to beginning of next (count in minute to minute ½ increments) o Duration-beginning of contraction to the end of same contraction (rounded to nearest 10 secs)  Strength: not reliable for external monitor (subjective) Internal monitor (IUPC)  Timing: same as external monitor  Strength: measure Montevideo units o Measure actual value of height of each contraction for 10 minutes & total it o Adequate labor ~200 (anything less = inadequate labor) o Go from baseline to peak  Tachysystole: Five contractions or more in a 10 minute period  Correlate fetal heart rate with contraction to evaluate response to labor Fetal Heart Rate (FHR):  Baseline: range of FHR during a continuous 10-minute period of monitoring (110-160 bpm)  Baseline variability: irregular fluctuations in baseline  Accelerations: Abrupt increase in FHR  Decelerations: Abrupt decrease in FHR  Tachycardia : a rate of 160 bpm or more for 10 minutes Bradycardia : FHR less than 110 bpm for more than 10 minutes  Variability tells if the baby’s system is adequate Baseline Variability:  Irregular fluctuations in baseline  Normal  Describe as: o Absent o Minimal-less than 5 bpm o Moderate-6-25 bpm o Marked-greater than 25 bpm o Sinusoidal pattern-fetal hypoxiaTachycardia >160:  Can be an early sign of fetal hypoxemia  Maternal or fetal infection  Fetal anemia  Maternal hyperthyroidism  Response to drugs Bradycardia <110:  Differentiate from decelerations  Late sign of fetal hypoxia  Drugs  Cord compression  Maternal hypothermia  Maternal hypotension  Tachysystole o Contractions being too frequent Accelerations:  32 weeks and older o 15 bpm above baseline lasting 15 seconds or more  Younger than 32 weeks o 10 bpm above baseline lasting 10 seconds or more  Prolonged: longer than 2 min, less than 10 min Decelerations:  Variable: o Abrupt, random  Early: o Symmetrical & associated with contraction o Return by end of contraction o Expected towards the end of stage 1  Late: o Uteroplacental insufficiency-variety of reasons o Begins after contraction Early Decelerations: End of contraction lines up with the end of the deceleration  Tells us that the baby is okay: o Baby returns to baseline before end of contraction o Moderate variability (6 bpm or more) Late Decelerations:  When the HR does not return to baseline at the end of the contraction  Minimal variability (shows that baby is not compensating well)Variable Decelerations:  Baseline normal  Moderate variability  Women is pushing/throwing up (why contractions look like that) Category Interpretation:  Category I (normal): strong predictor of normal fetal acid-base status, routine care, no action needed.  Category II (indeterminant): not predictive of abnormal acid-base status, but no evidence showing category I or III. Requires continuous surveillance and re-evaluation.  Category III (abnormal): abnormal fetal acid-base status. Needs prompt evaluation & actionVEAL CHOP: Dilation/effacement/station  Effacement – the taking up, drawing up, and disappearance of internal os and cervical canal into the uterine side walls  Dilation – widening of cervical os and cervical canal from less than a cm to approximately 10 cm  Station- Fetal station refers to where the presenting part is in your pelvis ROM, PROM, PPROM PROM & PPROM:  Premature rupture of membranes (PROM) o Rupture of amniotic sac and leakage of amniotic fluid beginning at least 1 hour before onset of labor at any gestational age o Nitrazine: amniotic fluid will be higher than 6.5-alkaline o Fern test: fluid on slide and let dry-fern pattern o If no labor in 12 hours, usually will induce-some will wait 24 hours o Monitor s/s of infection and fetal tolerance  Preterm premature rupture of membranes o Membranes rupture before 37 weeks of gestation and not in labor o Occurs in up to 25% of preterm labor cases o Often preceded by infection o Etiology unknown o Diagnosed after woman complains of sudden gush or slow leak of vaginal fluid o Care management: home vs. hospital Complications: prolapsed cord, shoulder dystocia, previa, abruption Prolapsed Cord:  Occurs when the cord lies below the presenting part of the fetus Contributing factors: Long cord, malpresentation (breech or transverse lie), or an unengaged presenting part  If the presenting part does not fit snugly into the lower uterine segment, when the membranes rupture, a sudden gush of amniotic fluid may cause the cord to be displaces downward  The cord may prolapse during amniotomy if the presenting part is high  A small fetus may not fit snugly into the lower uterine segment; as a result, cord prolapse is more likely to occur Shoulder Dystocia:  A condition in which the head is born, but the fetal shoulders are unable to pass through the maternal pelvis  Results from size discrepancy between the fetal shoulders and the pelvic inlet, which may be absolute or relative because of malposition  Risk factors: History of shoulder dystocia, maternal diabetes, and prolonged second stage of labor  Signs that indicate shoulder dystocia: Slowing of the process of the second stage of labor and formation of a caput succedaneum  Complications: Fracture of clavicle or humerus and unilateral brachial plexus injury  Nurse should use McRoberts maneuver (knees flexed to chest) Placenta previa: o Placenta implanted over cervix o Partial or complete o PAINLESS vaginal bleeding o Cannot vaginally deliver o Risks  More pregnancies (more scar tissue in the uterus)  Multiple surgeries  Fibroids  Multifetal pregnancies (twins, triplets) Abruptio placentae (placental abruption): o Detachment of placenta before birth of infant o Partial or complete o PAINFUL vaginal bleeding  Can have it without bleeding o Causes  Trauma to the abdomen (fall, car accident)  Drug use (cocaine, marijuana) Vacuum & forceps: use & precautions & complications Forceps Assisted Birth:  One in which an instrument with 2 curved blades is used to assist in the birth of the fetal head Indications- Prolonged second stage of labor and the need to shorten the second stage of labor for maternal reasons; Main indication is suspicion of fetal compromise  Complications- Vaginal or cervical lacerations, urinary retention, and hematoma formation in the pelvic soft tissues, which can result from blood vessel damage  The infant should be assessed for bruising or abrasions at the site of the blade applications, facial palsy resulting from pressure of the blades on the facial nerve, and subdural hematoma  Because compression of the cord between the fetal head and the forceps will cause a decrease in FHR, FHR is assessed, and recorded before and after the application of the forceps  Forceps o FHR monitoring is important! o Assess for trauma after delivery Vacuum-Assisted Birth:  A birth method involving the attachment of a vacuum cup to the fetal head, using negative pressure to assist in the birth of the head  Used to assist birth before 34 weeks of gestation  Prerequisites for use: Informed consent, completely dilated cervix, ruptured membranes, engaged head, vertex presentation, and no suspicion of CPD  Advantages: Ease with which the vacuum extractor can be placed and the need for less anesthesia  Vacuum o Preferred assistive method o Record # of attempts and time o Caput/cephalohematoma o Cerebral irritation-poor feeding, listless o Jaundice from bruising Med calculations including Pitocin drip calculationsLabor pain management Influences on Pain During Labor:  Physical o Visceral pain  Uterine ischemia  Cervical changes  Uterine distention  Referred pain o Somatic pain  Distention & pressure  Traction (on peritoneum)  Laceration  Psychosocial o Culture o Anxiety o Past experience o Preparation o Support o Environment Pain Distribution in Labor: Stage 1 Stage 2 Late stage 2 Pharmacologic Pain Management:  Type of med is situation specific  Sedatives: prolonged latent phase  Systemic analgesia: IV med, crosses placenta o Need to know onset, duration, and peak to know if it will affect the fetus o Opioid agonist: morphine, Fentanyl, remifentanil (Ultiva) o Opioid agonist-antagonist: Stadol, Nubain  Inhaled anesthetic: Nitrous Oxide  Regional analgesia & anesthesia o Blocks: local tissue, Pudendal o Spinal anesthesia: epidural (does not affect baby unless it drops the moms BP), spinal block (C/S) Epidural = active phase (3-4 cm)  20 minutes to take effect  General anesthesia: C/S only Pudendal Block: Gate-Control Theory:  How can painful stimuli be ignored?  Only limited number of sensory messages can travel nerve pathways at the same time  Distraction techniques block some of these, closing a “gate”  Engaging in activity involving the spinal cord modifies transmission as well  Cognitive work-concentration on breathing Nonpharmacologic Methods:  Preparation: Lamaze (breathing), Bradley (partner-coached breathing), Dick-Read (taking away fear of the unknown)  Techniques o Relaxation, focus, breathing o Effleurage(light touch on the abdomen) & counterpressure (putting severe pressure on the lower back) o Music o Water therapy o Massage, heat o Others: TENS, Acupressure/puncture, hypnosis, biofeedback, aromatherapy, intradermal water block Positions for labor  Latent- Walk around  Active- Get in bed, get on all fours Epidural: nursing care and assessment  Induction/augmentation, readiness for labor induction Induction:  Cervical ripening o Bishop score o Chemical vs mechanical AROM  Cytotec (Misoprostol)  Oxytocin/Pitocin Augmentation:  Active management o AROM (amniotomy), oxytocin  Forceps: shorten 2nd stage, unable to push effectively, breech, malpresentation, arrest of rotation  Vacuum: preferred over forceps  Other methods to stimulate contractions Bishop Score of 8 or Higher Indicates that the Cervix is Favorable for Induction: Chemical Induction Methods: Mechanical Induction Methods:Meds: Fentanyl, Stadol, Pitocin, Methergine, Hemabate, Misoprostol, Nubain, Betamethasone, Magnesium Sulfate, Terbutaline, nifedipine, indomethacin Medications Action Why used in L&D Misoprostol (Cytotec) Binds to myometrial cells causing strong contractions and ultimately resulting in the expulsion of tissue For the induction of labor and cervical ripening ; Abortion Oxytocin (Pitocin) (IV, IM) Increases the amplitude and frequency of uterine contractions, which transiently impede uterine blood flow and decrease cervical activity, causing dilation and effacement of the cervix Increases uterine activity and stimulates childbirth Postpartum uterine bleeding (hemorrhage) Abortion Nifedipine (Procardia) Inhibits the entry of calcium ions by blocking these voltage-dependent L-type calcium channels in vascular smooth muscle and Prolongation of pregnancy to enhance fetal lung maturitymyocardial cells Nubain Agonist-antagonist analgesic that stimulates kappa opioid receptors and blocks or weakly stimulates mu opioid receptors, resulting in good analgesia but with less respiratory depression and nausea and vomiting when compared to opioid agonists. Moderate to severe labor pain and post operative pain after c-section Stadol Mixed agonistantagonist analgesic that stimulates kappa opioid receptors and blocks or weakly stimulates mu opioid receptors, resulting in good analgesia but with less respiratory depression and N/V when compared with opioids Moderate to severe labor pain and postoperative pain after cesarean birth Methergine This medicine works by acting directly on the smooth muscles of the uterus and prevents bleeding after giving birth. To prevent and control bleeding from the uterus that can happen after childbirth Hemabate Oxytocic medications have the effects of oxytocin, which causes contractions during labor and controls bleeding after childbirth. Carboprost works on prostaglandin F receptor sites in Hemabate is used to treat severe bleeding after childbirth (postpartum). Hemabate is also used to produce an abortion by causing uterine contractionsuterine muscle to increase contractions and induce labor. Magnesium Sulfate Blocks neuromuscular transmission and decreases the amount of acetylcholine liberated at the end plate by the motor nerve impulse Used to stop preterm labor For women with preeclampsia First-line management of an eclamptic seizure First-line treatment of any seizure during pregnancy Neuroprotection of preterm infants Betamethosone It works by activating natural substances in the skin to reduce swelling, redness, and itching Betamethasone and dexamethasone are the most widely studied corticosteroids, and they generally have been preferred for antenatal treatment to accelerate fetal organ maturation Indomethacin It works by inhibiting the production of prostaglandins, which normally induce contractions Indomethacin can reduce the number and frequency of contractions Terbutaline Produces relaxation of smooth muscle found in bronchial, vascular and uterine tissues Stop or prevent premature labor (stops contractions) Fentanyl Opioid agonist analgesic that stimulates both mu and kappa opioid receptors to decrease the transmission of pain impulses Moderate to severe labor pain and postoperative pain after cesarean birth C/S: incision types, nursing care & prep, post-op care Techniques:  Horizontal/Low Segment/Pfannenstiel/Low transverse Classical/Vertical Nursing Prep:  Before going in to OR o Labs/IV-large bore needle o Gown/cap/remove jewelry/shave o Last PO intake o Antacid (famotidine/omeprazole/bicitra) o Metal in body?  In OR o Spinal o Catheter o SCD’s, Bair Hugger o Cautery grounding o Draping & abd prep https Postpartum Care:  PACU for about 1-2 hours  Q 15 min checks o Fundus o VS/cardiac monitor o Bleeding: vaginal & incision o Dermatomes  Baby in PACU when stable o Initiate breastfeeding SCD’s & F/C for about first 12 hours  IV & Pitocin  Ice to incision & vaginal if needed  TOLAC: in hospital, monitored, caution for uterine rupture, no cytotec! Postpartum (20%) Immediate pp care and assessment for vaginal or C/S delivery  Vaginal Delivery o Stay in L & D room for 1-2 hours-depends on recovery o VS q 15 for 1-2 hours o Bleeding  Fundal massage (always 1st action!)  Give pitocin-IV or IM  Ice to perineum o Pain meds o Breastfeeding o Bladder o Ambulation  *Watch for BP drop first time OOB*  C-section Delivery o PACU for ~2 hours  Dependent on return of sensation from spinal (Labor and delivery total time 3 hours) o VS q 15 & ECG/O2 sats o Bleeding & surgical site  Fundal massage  Pitocin IV  Ice to surgical site o SCD’s/Foley o Meds: antiemetics? pain? itching? o Assess dermatomes o Breastfeeding? BUBBLE-E assessment parameters Breasts:  Maternal physical changes o Oxytocin release stimulates prolactin and production of milk and let-down  Milk is released by contractions of alveoli in the breast o Colostrum is first milk secreted and is rich in protein and immunoglobulins o Primary engorgement occurs on the 2nd or 3rd day as transitional milk is produced o Mature milk in 2 weeks- but still changing  Assessmento Breast or bottle feeding o Palpate for engorgement for tenderness o Inspect nipples for redness, cracks, and erectility, if nursing Uterus:  Maternal physical changes o Involution: Uterus returns to pre-pregnant state o Subinvolution: Failure of the uterus to return to pre-pregnant state; often from retained fragments and seen with late postpartum bleeding o Contractions: Also called afterpains; More painful for multiparous women & with breastfeeding  Assessment o Palpate fundus o Firmness, height of fundus, and position in relation to midline of the abdomen o Correlate fundal location with expected descent of 1 cm each postpartal day Bladder:  Urinary system o Increased capacity, decreased tone of bladder o Full bladder displaces uterus o Postpartal diuresis-during first 12-24 hours o Void within 6 to 8 hours after delivery o Assess urinary frequency,  Burning, or urgency may indicate UTI o Able to empty bladder? o Palpate for bladder distention-why is that important? Bowel:  GI-Risk for constipation increases o May not have BM for 2-3 days post delivery o Assess distention, flatus, bowel sounds o More important with post-op o Stool softeners o Abdomen  Decreased muscle tone  Striae-red (or dark)-fades to silver later  Separation of rectus muscles Lochia:  Maternal physical changes o Lochia rubra (dark red)  Blood and decidual and trophoblastic cells  Duration of 3-4 days o Lochia serosa (pinkish brown)  Old blood, serum, leukocytes, and debris  Occurs 4-10 days pp o Lochia alba (whitish yellow)o Leukocytes, decidua, epithelial cells, mucus, serum, and bacteria o Continues 10 days and up to 4-8 weeks after birth o Cervix- Closes 2-3 cm after several days o Admits a fingertip after 1 week  Assessment o Inspect type, amount, and odor o Correlate with expected characteristics of bleeding  Heavy: one pad saturated within 2 hours or less o Cesarean-delivered females may have less lochia Episiotomy/Laceration Care & Extremities:  Inspect perineum for REEDA (Redness, Edema, Ecchymosis, Discharge, Approximation)  Inspect for perineal lacerations  Inspect abdominal incisions, cesarean delivery, tubal ligation  S/s of infection  Inspect for hemorrhoids  Hematoma  Surgical incision: REEDA also Extremities:  Edema  Varicosities  Sensation Emotional Status:  Assessment o Appropriate for situation o Phase of postpartal psychological adjustment o Assess for signs of postpartum blues o Assess parental interaction with newborn  Adjustment phases: Mom o Taking in  First 24 hours focus on self care and basic needs o Taking hold  2nd to 3rd day, focus on care of the baby o Letting go  Several weeks after birth, moving forward as a family  Adjustment phases: Partner o Expectations o Reality o Involved role o Reaping rewards Postpartum complications: causes, s/s, interventions Postpartum Complications:Physical Complications:  Lacerations of genital tract o Cervical lacerations different degree lacerations o Suspect if fundus firm, but bleeding  Hematoma o Pathophysiology-a collection of blood often in vulva or vagina that occurs as a result of injury to blood vessels during spontaneous delivery  Predisposing variables o Prolonged pressure of fetal head on vaginal mucosa o Operative delivery (forceps or vacuum extraction) o Precipitous labor or prolonged 2nd stage of labor o Macrosomia o Pudendal block Postpartum Infections:  Puerperal Sepsis o Any infection within 42 days after abortion or birth  Most common-numerous streptococcal and anaerobic organisms  Predisposing factors: prolonged rupture, C/S, invasive interventions, retained placenta, pre-existing infection  Assessment findings: temp, abnormal lochia, poor involution, tachy, pain  Labs: WBC increase greater than 30% in 6 hours indicates pathology (increased neutrophils & immature bands)  Endometriosis o Begins locally at placental insertion site  Wound infections o Often develop at home UTI o 2-4% of postpartum patients o Risk factorso Symptoms-  Mastitis o Unilateral, common week 2-4 o S. aureus o Pain, swelling, fever, redness, axillary adenopathy o Tx: abx, heat, analgesics, pump or breastfeed Thrombophlebitis:  Superficial or deep vein  Results from blood clot caused by inflammation or partial obstruction of vessel  Incidence and etiology o Venous status o Hypercoagulation  Clinical Manifestations o Pain and tenderness in lower extremities (LE) o Warmth, redness, enlarged & hardened vein o Assess pulses, measure calf  Medical management o NSAIDS/heparin/warfarin/ Lovenox o Ted hose/labs  Nursing management o Frequent assessment-watch for PE o Rest/elevate/ambulate later o No massage o Measure daily o Be aware of s/s of PE: chest pain, cough, dyspnea, decreased LOC Birth Trauma:  Uterine displacement and prolapse o Posterior displacement, or retroversion o Retroflexion and anteflexion o Prolapse, Cystocele and rectocele  Cystocele o Bladder prolapse  Rectocele o Rectal wall herniation  Urinary incontinence o Unable to hold bladder o Leaking with coughing, laughing, sneezing  Genital fistulas o Vesicovaginal: between bladder and genital tract o Urethrovaginal: between urethra and vagina o Rectovaginal: between rectum or sigmoid colon and vaginaPostpartum hemorrhage s/s, interventions, meds Postpartum Hemorrhage:  Defined as a loss more than o 500 ml of blood after vaginal birth and o 1000 ml after cesarean birth  Classified as early or late o Early: less than 24 hours after birth o Late: more than 24 hours/less than 6 weeks  Risk factors o History o Distended uterus-multiples o Long Labor o Traumatic Labor o C/S o Infection  Uterine Atony o Marked hypotonia of uterus o Leading cause of PPH, complicating approximately 1 in 20 births  Retained placenta o Non-adherent retained placenta o Adherent retained placenta: accrete/increta/percreta o Risk factors PPH Management:  Assessments o Bleeding/perineum/fundus/pain/VS/LOC/ labs/bladder  Medical management o Meds (oxytocin, methergine, hemabate, Cytotec, TXA) /fluids/blood  Nursing interventions o Frequent assessment-how often? o Massage boggy uterus-FIRST ACTION! and then continuous! o Encourage frequent voiding o Replace fluids Postpartum patient education: major points for discharge teachingDischarge Teaching:  Activity  Diet/vitamins  Infant feeding: breast/bottle  Peri-care/lochia  Incision care/episiotomy care  Constipation/hemorrhoids  Postpartum blues/depression  Family planning  Infant care and normal newborn characteristics  Danger signs for mom and infant (when to call provider) Breastfeeding: colostrum, types of milk and education for moms, mastitis, engorgement, breastfeeding holds  Maternal physical changes o Oxytocin release stimulates prolactin and production of milk and let-down  Milk is released by contractions of alveoli in the breast o Colostrum is first milk secreted and is rich in protein and immunoglobulins o Primary engorgement occurs on the 2nd or 3rd day as transitional milk is produced o Mature milk in 2 weeks- but still changing  Breastfeeding holds o Football or clutch: Under the arm; Most preferred o Across the lap (cross-cradle or modified cradle); Works well for early feedings, especially with smaller babies o Cradle; Most common position for infants who have learned to latch easily and feed effectively o Side-lying; Allows mother to rest while breastfeeding  Assessment o Breast or bottle feeding o Palpate for engorgement for tenderness o Inspect nipples for redness, cracks, and erectility, if nursing  Mastitis o Unilateral, common week 2-4 o S. aureus o Pain, swelling, fever, redness, axillary adenopathy o Tx: abx, heat, analgesics, pump or breastfeed Postpartum blues/depression/depression with psychosis: difference between these and patient/family education PP Blues vs. Depression:  Many s/s of PP blues overlap with PP depression s/s o Sadness, restlessness, fatigue, insomnia, headaches, anxiety, & intense sadness can be seen with botho Irritability & mood swings, more intense anxiety or panic, pp OCD, or any significant change in s/s from pp blues manifestation can signal pp depression o Symptoms lasting more than 10 days needs to be evaluated  PP depression can occur within the 1st year pp; most cases manifest in 1st 4 weeks  Edinburgh Postnatal Depression Scale (EPDS): screens for pp depression o Done on all pp patients prior to discharge @ VCU o Score of 12 or higher, or affirmative on question 10 (suicidal thoughts), needs further evaluation  Remember: these patients may present in offices or ED several weeks postpartum-be alert!  Make sure to educate partner & family on s/s to watch out for! Psychological Complications:  Postpartum depression without psychotic features- 9-24% of moms o PPD: An intense and pervasive sadness with severe and labile mood swings  Risk factors o Low self esteem o Stress of child care or life stress o Prenatal anxiety o No social support o Relationship problems o History of depression o Infant w/ problems or fussy; if have severe pp blues  Symptoms/Defining characteristics o Sadness o Frequent crying o Insomnia o Appetite change o Difficulty concentrating and making decisions o Feelings of worthlessness o Obsessive thoughts of inadequacy as a person/parent o Lack of interest in usual activities o Lack of concern about personal appearance o Irritability o Hostility toward newborn  Treatment Options o Antidepressants, anxiolytic agents o Zuranolone (Zurzuvae): newly approved for PPD-onset 3 days, can d/c in 2 weeks o Psychotherapy focuses on fears and concerns of new responsibilities and roles, and monitoring for suicidal or homicidal thoughts PPD With Psychotic Features:  Syndrome characterized by depression, delusions, and thoughts of harming either the infant or herself  Psychiatric emergency; may require hospitalization  Symptoms/defining characteristics o Agitation o Hyperactivityo Insomnia o Mood lability o Confusion o Irrationality o Difficulty remembering or concentrating o Poor judgment o Delusions o Hallucinations o Thoughts of harming self or baby  Treatment o Antipsychotics and mood stabilizers Parental stages: Taking in/taking hold/letting go  Adjustment phases: Mom o Taking in  First 24 hours focus on self care and basic needs o Taking hold  2nd to 3rd day, focus on care of the baby o Letting go  Several weeks after birth, moving forward as a family Newborn (20%) Apgar scoring Sign 0 1 2 Heart rate Absent Slow <100/min > or equal to 100/min Respiratory effort Absent Slow, weak cry Good cry Muscle tone Flaccid Some flexion of extremities Well flexed Reflex irritability No response Grimace Cry Color Blue, pale Body pink, extremities blue Completely pink Newborn reflexes: how to elicit them  Root, Suck, & Swallow  Extrusion: When your baby pushes solid food out of their mouth using their tongue  Grasp: palmar & plantar  Tonic neck (fencing): This reflex occurs when the side of the infant's spine is stroked or tapped while the infant lies on the stomach. The infant will twitch their hips toward the touch in a dancing movement. Moro (startle): The Moro reflex is a normal reflex for an infant when he or she is startled or feels like they are falling  Stepping: This reflex is also called the walking or dance reflex because a baby appears to take steps or dance when held upright with their feet touching a solid surface  Babinski: The Babinski reflex occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toes fan out Newborn assessment parameters: normal and normal variants  Physical assessment o Vital signs/weight/measurements  Temperature. Able to maintain a stable body temperature of 97°F to 98.6°F (36.5-37.5 celcius) in a normal room environment.  Heartbeat. Normally 120 to 160 beats per minute. It may be much slower when an infant sleeps.  Breathing rate. Normally 30 to 60 breaths per minute.  Blood pressure. Normally an upper number (systolic) between 60 and 80, and a lower number (diastolic) between 45 and 50.  Oxygen saturation. Normally 95% to 100% on room air. o Gestational age assessment o Skin  Color, texture, nails, presence of rashes o Head and Face  Appearance, shape, and shaping of the head from passage through the birth canal (molding)  The open soft spots between the bones of the baby's skull (fontanels)  Bones across the upper chest (clavicles)  Eyes, ears, nose, cheeks. Presence of red reflex in the eyes o Chest/Abdomen/Genitalia/Anus/Elimination  Abdomen. Presence of masses or hernias.  Genitals and anus. Open passage for urine and stool and normally formed male and female genitals.  Heart sounds and femoral (in the groin) pulses  Lungs. Breath sounds, breathing pattern. o Extremities & Spine o Neuro  Tone, neonatal reflexes are assessed Newborn nutrition & breastfeeding basics: ensuring adequate feeding, stool characteristics  Infant’s output o As the volume of breast milk increases, urine becomes dilute and should be light yellow o Infants should have 6-8 sufficiently wet diapers every 24 hours after day 4 o Baby should not be passing meconium after day 3-4 o Infants should have at least 3 stools per day in the first month  Breastfeeding basics o Breastfed babies should eat 8-12 times in a 24 hour periodo Parents need to awaken the baby to feed at least every 3 hours during the day and every 4 hours at night o Infants should be fed whenever they exhibit feeding cues, alerting the parent that they want to feed  Stool characteristics o Meconium followed by transitional and soft and yellow stool  The first stool your baby passes is thick, greenish black, and sticky. It's called meconium. The stools usually change from this thick, greenish black to green in the first few days. They'll change to yellow or yellowish brown by the end of the first week. Jaundice: physiologic & pathologic; kernicterus Physiologic Jaundice:  Occurs in 60% of newborns  Causes: increased bilirubin production, short RBC lifespan, & immature liver  Begins after 24 hours of age  Cephalocaudal distribution-blanching-sclera  Kernicterus-results from bilirubin >20 to 25  Early & frequent feedings help decrease bili Pathologic Jaundice:  Bilirubin can accumulate to hazardous levels and lead to a pathologic condition  Unconjugated hyperbilirubinemia that is either pathologic in origin or severe enough to warrant further evaluation and treatment  Jaundice is usually considered pathologic if it appears within 24 hours after birth, TSB levels increase by more than 0.2, TSB is greater than the 95th percentile for age in hours, direct serum bilirubin levels exceed 1.5-2, or clinical jaundice lasts more than 2 weeks Kernicterus:  Kernicterus, or bilirubin encephalopathy, is bilirubin-induced neurological damage, which is most commonly seen in infants. It occurs when the unconjugated bilirubin (indirect bilirubin) levels cross 25 mg/dL in the blood from any event leading to decreased elimination and increased production of bilirubin.  S/S: Poor feeding, irritability, no startle reflex, high pitched cry, lethargy, brief pauses in breathing, floppy muscles Rh incompatibility & RhoGAM vs. ABO incompatibility Rh Incompatibility:  When the mother is Rh negative and the fetus is Rh positive  Typically has no effect during the first pregnancy because the sensitization to Rh antigens rarely occurs before the onset of labor  Can be treated with fetal blood transfusions or IVIg  Can be prevented with RhoGAM ABO: When the major blood group antigens of the fetus are different than those of the mothers  Naturally occurring anti-A or anti-B antibodies already present in the maternal circulation crosses the placenta and attack the fetal RBC’s, causing hemolysis  Jaundice may appear shortly after birth  Treatment = phototherapy and exchange transfusions Pre-term & Post-term newborn characteristics & related issues Post term:  Creases on feet  Sparse vernix/lanugo  Long nails  Abundant scalp hair  Cracked, peeling skin  Wasted physical appearance that reflects placental insufficiency  Depletion of subcutaneous fat gives them a thin, elongated appearance  The scant amounts of vernix in the skinfolds may be stained green or yellow (meconium in amniotic fluid)  Increase in fetal mortality Preterm:  Increased risk for morbidity and mortality  Higher risk for hypoglycemia  Respiratory distress syndrome  Transient apnea of the newborn  Greater likelihood of NICU admission Terminology: IUGR, SGA, LGA, LBW, VLBW, ELBW  IUGR: Found in infants whose uterine growth is restricted  Macrosomia: A baby who is diagnosed as having fetal macrosomia weighs more than 8 pounds, 13 ounces (4,000 grams), regardless of his or her gestational age  SGA: Small for gestational age- An infant whose rate of intrauterine growth was slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves  LGA: Large for gestational age - Infant whose birth weight falls above the 90th percentile on intrauterine growth charts  LBW: Low birth weight - Infant whose birth weight is less than 2500g (5 lbs, 8 oz) regardless of gestational age  VLBW: Very low birth weight - Infant whose birth weight is less than 1500 g (3 lbs, 5 oz)  ELBW: Extremely low birth weight- Infant whose birth weight is less than 1000 g (2 lb 3 oz) NOWS: s/s, treatment, assessment S/S: crying, irritable, not sleeping, watery stools, not eating well, etc. Watch for dehydration b/c don’t feed well & diarrhea.  Treatment: - Medication, eat, sleep, console, limit stimulation, promote rooming in Cold stress with NB and preemies  When the neonate’s temperature drops, in response to norepinephrine release, vasoconstriction occurs as a mechanism to conserve heat  The infant can appear cool and mottled; the skin will feel cool especially in extremities  If the hypothermia is not corrected, it will progress to cold stress, which imposes metabolic and physiologic demands on all infants, regardless of gestational age and condition  The respiratory rate increases in response to the increased need for oxygen  When an infant is stressed by cold, oxygen consumption increases, and pulmonary and peripheral vasoconstriction occur, thereby decreasing oxygen uptake by the lungs and oxygen to the tissues; anaerobic glycolysis increases, and there is a decrease in PO2 and pH, leading to metabolic acidosis s/s of newborn resp distress  Nasal flaring, retractions, stridor, gasping, grunting, tachypnea Newborn diagnostic tests: Newborn screen, hearing screen, bili, blood glucose Newborn Tests:  Bilirubin o Routine before discharge or if baby looks jaundiced o You will hear TCB and TSB- TCB is Transcutaneous and TSB is Total Serum- TSB is more accurate  Newborn screening o PKU, hypothyroidism, others vary by state o Done after 24 hours old & at least one feeding  Hearing Screen o 30 states require it-most hospitals do it routinely o Repeat @ 2-8 weeks i